Anesthesiology and Pain Medicine
Volume:5 Issue: 5, Oct 2015

This is a case presentation of a 45-year-old male with chronic donor site pain following autologous iliac crest bone harvest successfully treated with superior cluneal nerve blockade. Donor site pain following autologous bone harvest is a common postoperative complication of lumbar fusion procedures that can cause significant morbidity and diminish quality of life, even in the context of an otherwise successful surgery. Dysfunction of the superior cluneal nerves is an etiology of this chronic pain. The patient’s medical history, attempted treatments, and literature were reviewed.. A 45-year-old male with a six year history of severe pain over the right iliac crest following an otherwise successful lumbar laminectomy and fusion underwent two sets of superior cluneal nerve blocks, with sustained relief of more than 80% at seven months follow up.. Donor site pain following autologous iliac crest bone harvest is a common surgical complication that is often resistant to conservative treatments such as physical therapy and oral medications. Blockade of the superior cluneal nerves is a safe and technically simple procedure that may result in long-term pain relief, obviating the need to consider more invasive options..

Epidural steroid injection (ESI), including transforaminal (TF) epidural injections and interlaminar (IL) epidural steroid injections are commonly performed procedures for the management of lumbosacral radicular pain. Parasagittal interlaminar (PIL) approach could enable higher ventral epidural spread, with fewer complications than TF.. This study aims to compare the effectiveness of PIL and TF ESI in relieving the pain and disability of patients with lumbosacral pain..Patients and This prospective study enrolled 64 patients, aged between 18 to 75 years, with a diagnosis of low back pain and unilateral lumbosacral radicular pain. The patients were randomized to receive fluoroscopically guided epidural injection, through either the PIL or TF approach. Patients were evaluated for effective pain relief [numerical rating scale (NRS) < 3] by 0 - 10 numeric rating scale (NRS) and functional improvement by the Oswestry Disability Index (ODI).. Effective pain relief [numeric rating scale (NRS) < 3] was observed in 77.3% (95% CI: 67‒90.5%) of patients in PIL group and 74.2% (95% CI: 62.4 - 89.4%) of patients in the TF group (P = 0.34), at 4 weeks. Mean NRS score was not significantly different between the PIL group compared to the TF group, at 4 weeks (P = 0.19). Number of patients with improved disability (measured by ODI < 20%) was not significantly different in PIL group (78% of cases) compared to the TF group (76% of cases), at 4 weeks (P = 0.21). There were no adverse effects observed in any of our patients.. The PIL epidural injection is as effective as TF epidural injection in improving pain and functional status, in patients with chronic lumbosacral low back pain, due to disc degeneration..

As pain and nausea is usually associated with endoscopy procedure, its management is important to alleviate patients’ anxious in this regard.. The present study aimed to examine the effectiveness of conversational hypnosis in reducing anxiety and endoscopy-related complications as well as its role in increasing the satisfaction of patients exposed to endoscopic procedures..Patients and The participants of upper GI endoscopy procedure were randomly assigned to an experiment group (with conversational hypnosis intervention, n = 93) and a control group (n = 47). The participants’ hemodynamic indexes (HR, blood pressure, pulse oximetry), anxiety, satisfaction level, and complications resulted from the procedure were monitored and included in the self-administered questionnaire.. The results indicated that the participants in experiment group had a significant reduction of anxiety in the posttest. The adverse side effects such as vomiting, nausea, and hiccups in the experimental group was less than the control group, though this difference was not significant (P = 0.54).. The results suggested that conversational hypnosis technique could reduce anxiety as well as the sedation process in invasive procedures such as endoscopy..

Postoperative cognitive dysfunction (POCD) is a serious and frequent complication after surgery, especially in elderly patients. Ketamine is an N-methyl D-aspartic acid receptor antagonist with demonstrated neuroprotective effects. An intravenous bolus of a sub-anesthetic dose (0.5 mg/kg) of ketamine can reduce postoperative delirium (POD) and POCD after cardiac surgery. But, the influence of ketamine on early POCD after non-cardiac surgery is unclear.. The current study aimed to evaluate the influence of ketamine on early postoperative cognitive function after orthopedic surgery in elderly patients..Patients and Fifty six elderly patients (> 60-years-old), scheduled for elective orthopedic surgery during general anesthesia (duration of anesthesia > two hours) were enrolled. Patients received intravenous bolus, a total of 3 mL mixed with 0.9% normal saline and 0.5 mg/kg ketamine (K group) or 3 mL of 0.9% normal saline (N group). Three neurocognitive function tests (mini-mental status examination, trail-making test, digit substitution test), and c-reactive protein (CRP) concentration were determined before surgery and on postoperative day one (POD 1) and postoperative day six (POD 6).. The two groups had similar demographic characteristics except for the gender. Surgical and anesthetic data were not significantly different. A statistically significant difference was observed in comparison of trail-making test score. Trail-making test score increased more in the N group (52.5 points) than the K group (13 points) at POD 1 (P = 0.047) compared with baseline scores. There were no significant differences in the mini-mental status examination, digit substitution test and CRP concentration at POD 1 and POD 6 between the two groups. POCD (the two Z-scores in more than two tests or the combined Z-score was 1.96 or more) was present in one patient (4%) in the K group at POD 6 (P = 0.98).. The incidence of POCD was not significantly influenced by a bolus dose of ketamine (0.5 mg/kg) after orthopedic surgery in elderly patients. There were no negative effects of ketamine on early POCD..

Pregabalin as a new anticonvulsant has been used in different pain treatments.. The aim of this study was to investigate the role of N-methyl-D-aspartate (NMDA) ligands in antinociceptive effect of pregabalin in mice using tail flick.. NMDA (15 and 30 mg/kg) as an agonist or MK801 (0.02 and 0.05 mg/kg) as an antagonist were injected intraperitoneally either alone or 15 minutes before antinociceptive dose of pregabalin (100 mg/kg). Then the latency times and %MPE were measured in the tail flick assay during 75 minutes.. NMDA and MK801 had no effects alone. NMDA pretreatment significantly decreased the latency times of pregabalin till 75th minutes. In NMDA pretreated groups, %MPE30 unlike %MPE75 decreased significantly compared to those of pregabalin. MK801 delayed the latency times in pretreated groups, but %MPE30 and %MPE75 did not change significantly compared to pregabalin alone.. Our findings support the role of NMDARs in pregabalin antinociception, because the NMDAR agonist, unlike the antagonist, decreased the antinociceptive effect of pregabalin, even if tail flick is not an adequate pain assessment method in this regard..

Painful diabetic peripheral neuropathy (DPN) is a long-term complication of type 1 and type 2 diabetes that majorly impacts quality of life. Its prevalence increases with age and duration of diabetes. It is more common in patients who have suboptimal glycemic control over several years. Because DPN may be resistant to conventional treatments, it is common for patients to only have partial pain relief. Therefore, new therapeutic options are needed for the condition.. The aim of the present study was to compare the efficacy of transcutaneous electrical nerve stimulation (TENS) and pulsed radiofrequency (PRF) lumbar sympathectomy in treating painful DPN..Patients and Sixty-five patients with painful DPN refractory to conventional treatment were randomly and evenly assigned to either the TENS or PRF lumbar sympathectomy groups. Pain evaluations were based on the 10-point numerical rating scale (NRS). Subjects were followed for three months and had a total of four study visits (baseline and 1 week, 1 month, and 3 months after treatment).. Sixty patients completed all study visits. In both groups, the NRS rating significantly decreased after treatment, with a marked pain reduction observed at the first follow-up evaluation. In the PRF group, the NRS decreased from 6.46 at baseline to 2.76 at the 1 week visit. One and 3 months after treatment, the NRS was 4.30 and 5.13, respectively (P < 0.0001). In the TENS group, the NRS decreased from 6.10 at baseline to 3.96 at the 1 week visit. One and 3 months after treatment, the NRS was 5.23 and 5.90, respectively (P < 0.0001). Unfortunately, the NRS steady increased almost back to baseline levels in the TENS group. The NRS only slightly increased during the follow-up period in the PRF group, but did not reach baseline levels.. Both TENS and PRF lumbar sympathectomy are promising pain relief treatments for painful DNP. However, PRF lumbar sympathectomy seems to have a superior efficacy. Further studies with a larger sample size and a longer follow-up period are needed..

Postoperative pain after major open gynecologic surgeries requires appropriate pain management.. This study aimed at comparing perioperative patient controlled epidural analgesia (PCEA) and patient controlled intravenous analgesia (PCA) after gynecologic oncology surgeries..Patients and In this clinical trial study, 90 patients with American society of anesthesiologists (ASA) class I or II scheduled for gynecologic oncologic surgeries were randomly allocated to two groups (45 patients each group) to receive: patient-controlled epidural analgesia with bupivacaine and fentanyl (PCEA group), or patient controlled intravenous analgesia (IV PCA group) with fentanyl, pethidine and ondansetron. Postoperative pain was assessed over 48 hours using the visual analog scale (VAS). The frequency of rescue analgesia was recorded. Occurrence of any concomitant events such as nausea, vomiting, ileus, purities, sedation and respiratory complications were recorded postoperatively.. There were no statistically significant differences in demographic data including; age, weight, ASA physical status, duration of surgery, intraoperative bleeding, and the amount of blood transfusion (P > 0.05), between the two studied groups. Severity of postoperative pain was not significantly different between the two groups (P > 0.05); however, after first patient mobilization, pain was significantly lower in the epidural group than the IV group (P < 0.001). There was no significant difference between the two groups regarding the incidence of complications such as nausea, vomiting, purities or ileus (P > 0.05). Nevertheless, the incidence and severity of sedation was significantly higher in the IV group (P < 0.001). Respiratory depression was higher in the IV group than the epidural group; this difference, however, was not significant (P = 0.11). In the epidural group, only 10 patients (22.2%) had mild and transient lower extremities parenthesis.. Both intravenous and epidural analgesic techniques with combination of analgesics provide proper postoperative pain control after major gynecologic cancer surgeries without any significant complications. Regarding lower sedative and respiratory depressant effects of epidural analgesia, it seems that this method is a safer technique for postoperative pain relief in these patients..

Major surgical procedures, such as gastrectomy, result in extensive postoperative pain, which can lead to increased morbidity, discomfort and dissatisfaction among the patients.. The aim of this study was to evaluate the effect of adding diclofenac suppositories or intravenous paracetamol, on morphine consumption and on the quality of postgastrectomy pain control..Patients and This randomized double blinded clinical trial was carried out in 90 patients with gastric cancer, who were candidates for gastrectomy, which were divided into three similar groups. The patients were transferred to an intensive care unit after the operation and received patient-controlled analgesia (PCA) with morphine, morphine PCA plus intravenous paracetamol 1 g, every 6 hours, and morphine PCA plus diclofenac suppositories, 100 mg every 8 hours. The patients were evaluated for up to 24 hours after the operation for the severity of pain, alertness, and opioid complications.. There was no significant difference in pain scores among the three groups (P values, after extubation, at 2, 4, 6, 12, 18 and 24 hours were 0.72, 0.19, 0.21, 0.66, 0.54, 0.56, and 0.25, respectively), although morphine consumption was greater in the morphine group, compared with the other two groups (21.4 ± 7.7 mg in morphine group vs. 14.3 ± 5.8 mg in morphine-paracetamol group and 14.3 ± 3.9 in morphine-diclofenac group; P = 0.001). In morphine group, during the first 24 hours, the patients had lower levels of consciousness (P values, after extubation, at 2, 4, 6, 12, 18 and 24 hour were 0.6, 0.95, 0.28, 0.005, 0.027, 0.022 and 0.004 respectively), even though the incidence of complications was similar among the three groups.. In this study, intravenous paracetamol or diclofenac suppositories, administered for postgastrectomy pain control, decreased morphine consumption by almost 32% and also improved alertness. Nevertheless, the amount of opioids did not affect the incidence of complications..

In patients undergoing septorhinoplasty, control of bleeding and hemodynamic variables is of great importance and laryngoscopy and tracheal intubation could be followed by a specific and transient increase in systemic blood pressure and heart rate.. This study aimed to examine the effects of oral gabapentin on hemodynamic changes, during direct laryngoscopy, and the amount of bleeding in the patients undergoing septorhinoplasty..Patients and In a double-blind clinical trial, 103 patients (American society of anesthesiologists class I, II) aged 18 - 45 years old, who were septorhinoplasty candidates, were randomly assigned into two groups, a 900 mg gabapentin group and placebo, in Amir-Al-Momenin academic hospital. The drug was prescribed to the patients orally, 2 hours before the operation. Anesthetic technique was similar for all the patients. Heart rate (HR), systolic (SBP) and diastolic blood pressures (DBP), mean arterial blood pressure (MAP), oxygen saturation percentage of arterial blood (SaO2), before induction of anesthesia, 3, 5, 10, and 15 minutes after the intubation and tracheal extubation, and the amount of bleeding during operation were measured. Statistical analysis was performed with the SPSS (v. 16) software.. Variations in the HR, DBP and SaO2, in the specified time intervals, did not show any statistically significant difference, although variations in SBP were statistically significant (higher in gabapentin group). Regarding the average amount of bleeding volume, although there was a lower amount of bleeding in the gabapentin group, the difference was not statistically significant. Also, regarding the pain, there was no significant difference between the two groups in terms of visual analog scale (VAS) average and the received analgesic.. The present study showed that premedication with 900 mg gabapentin did not affect the hemodynamic changes induced by laryngoscopy and the amount of bleeding. However, the decreased amount of bleeding was observed in the gabapentin group..

To report and discuss the spinal headache following insertion and removal of intrathecal drug delivery system in patients with chronic pain disorders.. Intrathecal drug delivery system (IDDS) was initially used for the management of chronic malignant pain; it has since been used to manage pain from other nonmalignant conditions as well. Spinal headache is one of the complications during the trial, permanent placement and after removal of intrathecal drug delivery catheter systems. A 48-year-male patient with chronic pain disorder developed a refractory spinal headache after removing the intrathecal drug delivery system requiring a surgical intervention to resolve the problem.. Conservative management is successful in the vast majority of patients with spinal headache. Interventional procedures are required in a small fraction of patients for symptomatic relief..